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Griffin M, Odanovic N, McNamara R, Altin SE, Balan S, Thompson J, Young LH. Intra-Aortic Balloon Pump Exacerbates Left Ventricular Outflow Tract Obstruction in a Patient With Takotsubo and Hypertrophic Cardiomyopathy. CASE (PHILADELPHIA, PA.) 2023; 7:502-507. [PMID: 38197115 PMCID: PMC10772928 DOI: 10.1016/j.case.2023.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
•Obstructive HCM with superimposed takotsubo syndrome led to shock. •The use of an IABP worsened outflow obstruction. •Putting the IABP on standby improved outflow tract gradients dramatically. •An IABP should not be used in shock with LVOT obstruction.
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Affiliation(s)
- Matthew Griffin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Critical Care Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Natalija Odanovic
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Institute for Cardiovascular Diseases “Dedinje”, Belgrade, Serbia
| | - Robert McNamara
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - S. Elissa Altin
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Samantha Balan
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jazmyn Thompson
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence H. Young
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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UMETSU AKIKO, MATSUSHITA SATOSHI, KINOSHITA TAKESHI, TABATA MINORU. Concomitant Septal Myectomy with Aortic Valve Replacement for Severe Aortic Stenosis with Left Ventricular Outflow Tract Obstruction. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2023; 69:203-215. [PMID: 38855434 PMCID: PMC11153074 DOI: 10.14789/jmj.jmj22-0036-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/06/2023] [Indexed: 06/11/2024]
Abstract
Objectives Septal myectomy confers survival benefits on patients with hypertrophic cardiomyopathy. However, its role in the treatment of severe aortic stenosis (sAS) with left ventricular outflow tract obstruction (LVOTO) remains under investigation. Another challenging question in the era of transcatheter aortic valve replacement is who would benefit more from traditional surgical aortic valve replacement (SAVR) with myectomy. Therefore, this study aimed to investigate myectomy cases at our hospital in Japan. Methods A total of 740 patients who underwent SAVR for sAS between 2012 and 2019 were identified. The demographics and baseline echocardiographic findings were retrospectively compared between patients who underwent concomitant myectomy and those who did not. The myectomy group was further assessed for factors predisposing to LVOTO, operative details, echocardiographic changes, and prognosis. The resected septa were histopathologically analyzed. Results The myectomy group mostly comprised elderly females with a small hypercontractile heart. Myectomy with SAVR led to statistically significant improvements in concentric left ventricular hypertrophy and LVOTO parameters. Survival was comparable with that reported in previous reports, even in the elderly subset (≥ 75 years). The septa showed mild fibrosis. Conclusions Myectomy can be safely performed with SAVR for sAS with LVOTO, even in the elderly, and it effectively improves LVOTO. Special attention should be paid to elderly females with relatively more severe AS and a small yet extra-hypertrophic and extra-hypercontractile heart. Such patients warrant comprehensive assessment of LVOTO, and despite its invasiveness, SAVR may be potentially more beneficial by allowing direct observation of LVOTO and ancillary myectomy.
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Affiliation(s)
| | - SATOSHI MATSUSHITA
- Corresponding author: Satoshi Matsushita, Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan, TEL: +81-3-3813-3111 E-mail:
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Alabdaljabar MS, Eleid MF. Dynamic Left Ventricular Outflow Tract Obstruction Exacerbated by Thoracic Kyphosis. JACC Case Rep 2022; 7:101710. [PMID: 36776797 PMCID: PMC9911919 DOI: 10.1016/j.jaccas.2022.101710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
We present a 74-year-old woman with kyphosis and symptoms of pre/syncope. Heart catheterization revealed dynamic left ventricular outflow tract obstruction (DLVOTO) with Brockenbrough Braunwald response only when kyphotic posture was assumed. She had a positive response to metoprolol. DLVOTO is a challenging diagnosis in the absence of resting LVOTO. (Level of Difficulty: Beginner.).
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Affiliation(s)
| | - Mackram F. Eleid
- Division of Interventional Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA,Address for correspondence: Dr. Mackram F. Eleid, Division of Interventional Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.
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Chou CJ, Lai YC, Ou SY, Chen CH. Unexpected systolic anterior motion of the mitral valve-related hypoxemia during transurethral resection of the prostate under spinal anesthesia: a case report. BMC Anesthesiol 2022; 22:207. [PMID: 35794519 PMCID: PMC9258149 DOI: 10.1186/s12871-022-01754-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Dynamic obstruction of the left ventricular outflow tract resulting from systolic anterior motion of the mitral valve can be an unexpected cause of acute and severe perioperative hypotension in noncardiac surgery. We report a patient undergoing spinal anesthesia for transurethral resection of the prostate who experienced sudden hypoxemia caused by systolic anterior motion-induced mitral regurgitation but with a clinically picture simulating fluid overload. Case presentation An 83-year-old man with a history of hypertension was scheduled for transurethral resection of the prostate. One hour after spinal anesthesia, he developed acute restlessness and dyspnea, with pink frothy sputum and progressive hypoxemia. Slight hypertension was noted, and an electrocardiogram showed atrial fibrillation with a rapid ventricular response. Furosemide and nitroglycerin were thus administered for suspected fluid overload or transurethral resection of the prostate syndrome; however, he then became severely hypotensive. After tracheal intubation, intraoperative transesophageal echocardiography was promptly performed, which revealed an empty hypercontractile left ventricle, significant mitral regurgitation and mosaic flow signal in the left ventricular outflow tract. Following aggressive fluid therapy, his hemodynamic changes stabilized. Repeat echocardiography in intensive care unit confirmed the presence of systolic anterior motion of the anterior mitral leaflet obstructing the left ventricular outflow tract. We speculate that pulmonary edema was induced by systolic anterior motion-associated mitral regurgitation and rapid atrial fibrillation, and the initial management had worsened his hypovolemia and provoked left ventricular outflow tract obstruction and hemodynamic instability. Conclusions Pulmonary edema caused by systolic anterior motion of the mitral valve can be difficult to clinically differentiate from that induced by fluid overload. Therefore, bedside echocardiography is paramount for timely diagnosis and prompt initiation of appropriate therapy in the perioperative care setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01754-x.
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Fujiwara M, Kawai K, Kanazawa N, Noguchi M, Hasokawa M, Nanahoshi M, Kobayashi S. Dynamic left ventricular outflow tract obstruction in a patient with acute coronary syndrome and without the apical akinesia: Potential alternative mechanisms causing a dynamic left ventricular outflow tract obstruction other than a compensatory basal hyperkinesis. Echocardiography 2021; 38:460-468. [PMID: 33629388 DOI: 10.1111/echo.14989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/09/2020] [Accepted: 01/11/2021] [Indexed: 11/30/2022] Open
Abstract
The mechanism for dynamic left ventricular outflow tract obstruction (LVOTO) after acute coronary syndromes (ACS) is thought to be apical infarction with compensatory hyperkinesia of the residual normally perfused basal segments of the myocardium. However, herein, we report a patient with ACS and dynamic LVOTO (peak gradient of 250 mm Hg at rest) that could not be secondary to apical akinesia. We propose a potential alternative mechanism leading to dynamic LVOTO in ACS, namely, the interplay between sigmoid septum, basal hyperkinesis, and outflow tract narrowing induced by afterload reduction due to acute myocardial ischemia itself.
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Affiliation(s)
- Momo Fujiwara
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kasai City Hospital, Hyogo, Japan
| | - Keisuke Kawai
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kasai City Hospital, Hyogo, Japan
| | - Natsuki Kanazawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kasai City Hospital, Hyogo, Japan
| | - Masamitsu Noguchi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kasai City Hospital, Hyogo, Japan
| | - Minoru Hasokawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kasai City Hospital, Hyogo, Japan
| | - Masakazu Nanahoshi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kasai City Hospital, Hyogo, Japan
| | - Seiichi Kobayashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kasai City Hospital, Hyogo, Japan
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Cardiogenic Shock Secondary to Dynamic Left Ventricular Outflow Tract Obstruction and Apical Ballooning after Nonmitral Cardiovascular Surgery. Case Rep Crit Care 2020; 2020:8826187. [PMID: 33294231 PMCID: PMC7716751 DOI: 10.1155/2020/8826187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 10/18/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022] Open
Abstract
Background The dynamic obstruction of the left ventricular outflow tract (LVOT) is a well-known complication in mitral annuloplasty but rarely seen in nonmitral cardiovascular surgery. The dynamic LVOT obstruction can lead to hemodynamic instability, even shock and the treatment is significantly different from the standard approach. Case Presentation. We reported a case of low cardiac output syndrome (LCOS) with severe mitral regurgitation (MR), dramatically reduced left ventricular ejection fraction (LVEF) after coronary artery bypass grafting in a 72-year-old female requiring an escalation of inotropic support, volume restriction, and mechanical support. The detailed echocardiography combined with lung ultrasound revealed a dynamic systolic anterior movement of the anterior mitral leaflet (SAM), apical ballooning, and no significant lung congestion. Intravenous fluids were given, diuretics withdrawn, inotrope discontinued, and vasopressors uptitrated. The dynamic SAM was rapidly relieved, the hemodynamics was stabilized, and the LVEF was improving. The patient was discharged in good condition without residual LVOT obstruction and trace MR. Conclusion We strongly suggest that a detailed echocardiography should be performed in any patient who presents in shock to rule out a dynamic LVOT obstruction. Lung ultrasound should be a routine examination in addition to echocardiography. Once SAM is detected, treatment should be based on volume expansion, inotrope discontinuation, and a careful afterload increasing.
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Raut M, Maheshwari A, Swain B. Awareness of 'Systolic Anterior Motion' in Different Conditions. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2018; 12:1179546817751921. [PMID: 29371788 PMCID: PMC5772485 DOI: 10.1177/1179546817751921] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 12/07/2017] [Indexed: 11/15/2022]
Abstract
Perioperative echocardiography, especially transesophageal echocardiography, is of paramount importance in evaluating and managing refractory hypotension, a potential cause of which is systolic anterior motion (SAM) of anterior mitral leaflet. Dynamically moving anterior mitral valve leaflet towards the left ventricular outflow tract (LVOT) is described as SAM. Although SAM was initially observed in patients with hypertrophic cardiomyopathy, it can also be seen in patients with complex dynamic anatomy of the left ventricle. Interestingly, SAM may or may not give rise to clinically significant LVOT obstruction. Hence, it is of paramount importance for perioperative physician to know such ‘dynamic SAM’ which can potentially and significantly affect and alter perioperative management.
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Affiliation(s)
- Monish Raut
- Department of Cardiac Anaesthesia and Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Arun Maheshwari
- Department of Cardiac Anaesthesia and Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Baryon Swain
- Department of Cardiac Anaesthesia and Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India
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Khanna S, Raval R, Dorotta I. Con: Dynamic Left Ventricular Outflow Tract Obstruction Should Be Considered an “Unexpected” Finding in Patients With End-Stage Liver Disease Undergoing Dobutamine Stress Echocardiography in Preparation for Liver Transplantation. J Cardiothorac Vasc Anesth 2017; 31:2293-2295. [DOI: 10.1053/j.jvca.2017.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Indexed: 01/09/2023]
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Meuwese CL, Boulaksil M, van Dijk J, Polad J, Meijburg HW. Transient left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve: A stunning cause. Echocardiography 2017; 34:1089-1091. [DOI: 10.1111/echo.13553] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Christiaan L. Meuwese
- Department of Cardiology; Jeroen Bosch Hospital; ‘s-Hertogenbosch The Netherlands
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Mohamed Boulaksil
- Department of Cardiology; Jeroen Bosch Hospital; ‘s-Hertogenbosch The Netherlands
- Department of Cardiology; Radboud University Medical Center; Nijmegen The Netherlands
| | - Jeroen van Dijk
- Department of Cardiology; Jeroen Bosch Hospital; ‘s-Hertogenbosch The Netherlands
| | - Jawed Polad
- Department of Cardiology; Jeroen Bosch Hospital; ‘s-Hertogenbosch The Netherlands
| | - Huub W. Meijburg
- Department of Cardiology; Jeroen Bosch Hospital; ‘s-Hertogenbosch The Netherlands
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Hertel T, Banayan JM, Chaney MA, von Dossow V, Dhawan R. Systolic Anterior Motion of the Mitral Valve With Left Ventricular Outflow Tract Obstruction: A Rare Cause of Hypotension After Lung Transplantation. J Cardiothorac Vasc Anesth 2017. [PMID: 28648775 DOI: 10.1053/j.jvca.2017.02.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Thomas Hertel
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Jennifer M Banayan
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| | - Vera von Dossow
- Department of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Richa Dhawan
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
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Uematsu S, Takaghi A, Imamura Y, Ashihara K, Hagiwara N. Clinical features of the systolic anterior motion of the mitral valve among patients without hypertrophic cardiomyopathy. J Cardiol 2017; 69:495-500. [DOI: 10.1016/j.jjcc.2016.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/24/2016] [Accepted: 04/14/2016] [Indexed: 11/16/2022]
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12
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Yalçin F, Muderrisoglu H, Korkmaz ME, Ozin B, Baltali M, Yigit F. The Effect of Dobutamine Stress on Left Ventricular Outflow Tract Gradients in Hypertensive Patients with Basal Septal Hypertrophy. Angiology 2016; 55:295-301. [PMID: 15156263 DOI: 10.1177/000331970405500309] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Basal septal hypertrophy (BSH), a cause of left ventricular outflow tract (LVOT) obstruction, is thought to occur by increased ventricular dynamics. The aim of the study was to evaluate the effect of pharmacologic stress on LVOT gradients in a group of hypertensive patients with BSH. Dobutamine stress was used in 24 hypertensive patients (mean age 56 ±8 years; 11 women) with BSH and 20 normal controls (mean age 54 ±9 years; 7 women). Ejection fraction and myocardial mass, basal septal dimension, and LVOT diameter were measured with 2-dimensional echocardiography. LVOT velocities and transmitral velocities before and at peak dobutamine infusion were determined by continuous wave Doppler and pulsed Doppler, respectively. There were no differences in mean ejection fraction and myocardial mass between BSH patients (58 ±3%, 204 ±24 g) and normals (56 ±4%, 201 ±32 g). The basal septum was thicker in patients (1.55 ±0.2 cm) than in normals (1.03 ±0.1 cm, p<0.001). Maximum LVOT velocities were similar in BSH (1.2 ±0.4 m/sec) and normals (1.1 ±0.2 m/sec) at rest. At peak stress, maximum LVOT velocities were higher in BSH (3.3 ±0.6 m/sec) than normals (1.7 ±0.4 m/sec, p<0.001). LV rate-pressure product at peak stress was higher in BSH (23,326 ±4,388) than normals (17,592 ±2,409, p<0.001). LV isovolumetric relaxation time was prolonged, and the E/A ratio was decreased in the patients at rest (130 ±14 msec and 0.72 ±0.18, respectively, p<0.001). At peak stress, diastolic function did not significantly change in two groups. The correlations between LVOT velocity change by stress and mean LVOT diameter ( r =-0.668, p<0.001) and mean BS thickness ( r =0.610; p<0.001) were significant in the whole group. High velocities appeared on LVOT at peak pharmacologic stress in the hypertensive patients with BSH compared with control group. This suggests dynamic ventricular ejection by stress may contribute to hypertrophy of the basal segment, which is the closest part of septum to increased afterload.
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Affiliation(s)
- Fatih Yalçin
- Başkent University School of Medicine, Department of Cardiology, Medical and Research Center, Adana, Turkey.
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Ha YR, Toh HC. Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review. J Intensive Care 2016; 4:54. [PMID: 27529030 PMCID: PMC4983789 DOI: 10.1186/s40560-016-0172-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 07/12/2016] [Indexed: 12/16/2022] Open
Abstract
Rapid and accurate diagnosis and treatment are paramount in the management of the critically ill. Critical care ultrasound has been widely used as an adjunct to standard clinical examination, an invaluable extension of physical examination to guide clinical decision-making at bedside. Recently, there is growing interest in the use of multi-organ point-of-care ultrasound (MOPOCUS) for the management of the critically ill, especially in the early phase of resuscitation. This article will review the role and utility of symptom-based and sign-oriented MOPOCUS in patients with undifferentiated respiratory difficulty, chest pain, or shock and how it can be performed in a timely, effective, and efficient manner.
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Affiliation(s)
- Young-Rock Ha
- Emergency Department, Bundang Jesaeng Hospital, 20 Seohyeon-ro 180beongil, Bundang-gu, Seongnam-si, Gyeonggi-do South Korea
| | - Hong-Chuen Toh
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, 90 Yishun Central, S768828 Singapore, Singapore
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Santoro F, Ieva R, Ferraretti A, Fanelli M, Musaico F, Tarantino N, Martino LD, Gennaro LD, Caldarola P, Biase MD, Brunetti ND. Hemodynamic Effects, Safety, and Feasibility of Intravenous Esmolol Infusion During Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction: Results From A Multicenter Registry. Cardiovasc Ther 2016; 34:161-6. [DOI: 10.1111/1755-5922.12182] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
| | - Riccardo Ieva
- Cardiology Department; University of Foggia; Foggia Italy
| | | | - Mario Fanelli
- Cardiology Department; University of Foggia; Foggia Italy
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Badran HM, Ibrahim WA, Faheem N, Yassin R, Alashkar T, Yacoub M. Provocation of left ventricular outflow tract obstruction using nitrate inhalation in hypertrophic cardiomyopathy: Relation to electromechanical delay. Glob Cardiol Sci Pract 2016; 2015:15. [PMID: 26779503 PMCID: PMC4448073 DOI: 10.5339/gcsp.2015.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/26/2015] [Indexed: 11/25/2022] Open
Abstract
Background: Left ventricular outflow tract obstruction (LVOT) is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). It is of major importance that the provocation modalities used are validated against each other. Aim: To define the magnitude of LVOT gradients provocation during both isosorbide dinitrate (ISDN) inhalation and treadmill exercise in non-obstructive HCM and analyze the correlation to the electromechanical delay using speckle tracking. Methods: We studied 39 HCM pts (64% males, mean age 38 ± 13 years) regional LV longitudinal strain and electromechanical delay (TTP) was analyzed at rest using speckle tracking. LVOT gradient was measured at rest and after ISDN then patients underwent a treadmill exercise echocardiography (EE) and LVOT gradient was measured at peak exercise. Results: The maximum effect of ISDN on LVOT gradient was obtained at 5 minutes, it increased to a significant level in 12 (31%) patients, and in 14 (36%) patients using EE, with 85.6% sensitivity & 100% specificity. Patients with latent obstruction had larger left atrial volume and lower E/A ratio compared to the non-obstructive group (p < 0.01). LVOTG using ISDN was significantly correlated with that using EE (p < 0.0001), resting LVOTG (p < 0.0001), SAM (p < 0.0001), EF% (p < 0.02) and regional electromechanical delay but not related to global LV longitudinal strain. Using multivariate regression, resting LVOTG (p = 0.006) & TTP mid septum (p = 0.01) were found to be independent predictors of latent LVOT obstruction using ISDN. Conclusion: There is a comparable diagnostic value of nitrate inhalation to exercise testing in provocation of LVOT obstruction in HCM. Latent obstruction is predominantly dependent on regional electromechanical delay.
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Affiliation(s)
| | | | - Naglaa Faheem
- Cardiology Department Menoufiya University, Egypt; The BAHCM National Program, Egypt
| | - Rehab Yassin
- Cardiology Department Menoufiya University, Egypt
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Ozaki K, Okubo T, Yano T, Tanaka K, Hosaka Y, Tsuchida K, Takahashi K, Miida T, Oda H. Manifestation of latent left ventricular outflow tract obstruction caused by acute myocardial infarction: An important complication of acute myocardial infarction. J Cardiol 2014; 65:514-8. [PMID: 25192592 DOI: 10.1016/j.jjcc.2014.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 07/28/2014] [Accepted: 08/03/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although transient left ventricular outflow tract (LVOT) obstruction is reported as a complication with acute myocardial infarction (AMI), the mechanisms and features of LVOT obstruction in AMI are unclear. METHODS AND RESULTS Herein, we present two cases of transient LVOT obstruction with anteroseptal AMI. The features of these two cases were one-vessel disease (1-VD) of the left anterior descending artery (LAD) and maintenance of blood flow to the major septal branch (SB). Moreover, LVOT obstruction was revealed after dobutamine infusion in the chronic phase and the aorto-septal angle was low in these two cases, meaning that latent LVOT obstruction was due to sigmoid-shaped septum. CONCLUSIONS Latent LVOT obstruction would be manifested in the acute phase of AMI. 1-VD of LAD and the maintenance of major SB blood flow are important factors with respect to the manifestation of latent LVOT obstruction.
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Affiliation(s)
- Kazuyuki Ozaki
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan.
| | - Takeshi Okubo
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Toshiaki Yano
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Komei Tanaka
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Yukio Hosaka
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Keiichi Tsuchida
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | | | - Tsutomu Miida
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital, Niigata, Japan
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Hymel BJ, Townsley MM. Echocardiographic Assessment of Systolic Anterior Motion of the Mitral Valve. Anesth Analg 2014; 118:1197-201. [DOI: 10.1213/ane.0000000000000196] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Place des inotropes en réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Gibson PH, Khandekar SA, Taylor D, Becher H. Hypertrophic cardiomyopathy with intermittent free mitral regurgitation-a surgical dilemma. Echocardiography 2014; 31:E107-10. [PMID: 24446781 DOI: 10.1111/echo.12519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We describe the case of a 52-year-old woman presenting with non-ST elevation myocardial infarction, atrial fibrillation, and a new diagnosis of hypertrophic cardiomyopathy. Transesophageal echocardiography following hemodynamic deterioration revealed completely restricted mitral leaflet motion with free mitral regurgitation, and severe left ventricular outflow tract (LVOT) obstruction. Surgical intervention was considered; however, repeat imaging following a period of clinical stability revealed resolution of the findings suggesting a transient ischemic etiology. The case is supported by clinical and echocardiographic images with movie clips, and a discussion of the likely pathology in the context of the underlying condition.
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Mun JB, Oh AR, Park HS, Park CH, Park KY, Moon J. The Unusual Suspect: Anemia-induced Systolic Anterior Motion of the Mitral Valve and Intraventricular Dynamic Obstruction in a Hyperdynamic Heart as Unexpected Causes of Exertional Dyspnea after Cardiac Surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:457-60. [PMID: 24368973 PMCID: PMC3868694 DOI: 10.5090/kjtcs.2013.46.6.457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/16/2013] [Accepted: 07/22/2013] [Indexed: 11/16/2022]
Abstract
Dynamic left ventricular (LV) outflow tract obstruction is a characteristic feature of hypertrophic cardiomyopathy; however, it can also occur in association with hyperdynamic LV contraction and/or changes in the cardiac loading condition, even in a structurally normal or near-normal heart. Here, we report a case of anemia-induced systolic anterior motion of the mitral valve and the resultant intraventricular obstruction in a patient who underwent coronary artery bypass grafting and suffered from anemia associated with recurrent gastrointestinal bleeding.
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Affiliation(s)
- Jeong-Beom Mun
- Presbyterian Medical Center, Gachon University of Medicine and Science, Korea
| | - Ah-Reum Oh
- Lee Gil Ya Cancer and Diabetes Institute, Gachon University of Medicine and Science, Korea
| | - Hwa-Sun Park
- Division of Cardiology, Department of Internal Medicine, Gachon University of Medicine and Science, Korea
| | - Chul-Hyun Park
- Division of Cardiology, Department of Internal Medicine, Gachon University of Medicine and Science, Korea
| | - Kook-Yang Park
- Division of Cardiology, Department of Internal Medicine, Gachon University of Medicine and Science, Korea
| | - Jeonggeun Moon
- Division of Cardiology, Department of Internal Medicine, Gachon University of Medicine and Science, Korea
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Kang S, An S, Yu HM, Kim J, Kim SH, Kim HJ, Chung SM. Cardiogenic shock accompanied by dynamic left ventricular outflow tract obstruction and myocardial bridging after transient complete atrioventricular block mimicking ST-elevation myocardial infarction: a case report. BMC Res Notes 2013; 6:478. [PMID: 24252345 PMCID: PMC3874663 DOI: 10.1186/1756-0500-6-478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 11/14/2013] [Indexed: 11/10/2022] Open
Abstract
Background Dynamic left ventricular outflow tract obstruction with or without mitral regurgitation is typically observed in hypertrophic cardiomyopathy, but is also occasionally seen without left ventricular hypertrophy. In this report, we present a case of cardiogenic shock that mimics ST-elevation myocardial infarction, due to dynamic left ventricular outflow tract obstruction with transient mitral regurgitation and myocardial bridging after transient complete atrioventricular block. Case presentation A 65-year-old man with hypertension presented himself at the emergency department with syncope after chest pain. His initial electrocardiography showed inferior ST elevation with profound precordial ST depression and transient complete atrioventricular block. Due to sustained hypotension, an intra-aortic balloon pump was applied. His coronary angiography revealed almost normal right coronary artery and left circumflex artery and only a severe myocardial bridge in the mid-segment of his left anterior descending artery. Instead, severe mitral regurgitation was found without regional wall motion abnormality both in the left ventriculography and the portable echocardiography. However the severe mitral regurgitation completely disappeared in follow up echocardiography the day after. The pressure gradient across the left ventricular outflow tract was measured at 8.95 mmHg during the resting state, and was increased to 38.95 mmHg during the Valsalva state. Conclusions The patient presented with a case of cardiogenic shock that mimicked ST-elevation myocardial infarction due to dynamic left ventricular outflow tract obstruction combined with myocardial bridging in the mid-left anterior descending artery.
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Affiliation(s)
| | | | | | | | - Sung Hea Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.
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Khan S, Ripley D, de Belder M, Goodwin A, Barham N, Wright R. Left ventricular outflow tract obstruction following an uncomplicated primary percutaneous coronary intervention: a recognized but rare cause of cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 2:68-71. [PMID: 24062935 DOI: 10.1177/2048872612471204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 11/25/2012] [Indexed: 11/16/2022]
Abstract
Dynamic left ventricular outflow tract obstruction is a rare but important complication of myocardial infarction. It occurs acutely and may mimic the presentation of papillary muscle rupture or acquired ventricular septal defect. Unlike these mechanical complications, it does not require circulatory support or cardiac surgical intervention. Recognition is critical because it typically responds to volume loading and beta blockade. We report a case who displayed many classical features of this condition.
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Affiliation(s)
- S Khan
- The James Cook University Hospital, Middlesbrough, UK
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23
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Kim D, Mun JB, Kim EY, Moon J. Paradoxical heart failure precipitated by profound dehydration: intraventricular dynamic obstruction and significant mitral regurgitation in a volume-depleted heart. Yonsei Med J 2013; 54:1058-61. [PMID: 23709446 PMCID: PMC3663219 DOI: 10.3349/ymj.2013.54.4.1058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Occurrence of dynamic left ventricular outflow tract (LVOT) obstruction is not infrequent in critically ill patients, and it is associated with potential danger. Here, we report a case of transient heart failure with hemodynamic deterioration paradoxically induced by extreme dehydration. This article describes clinical features of the patient and echocardiographic findings of dynamic LVOT obstruction and significant mitral regurgitation caused by systolic anterior motion of the mitral valve in a volume-depleted heart.
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Affiliation(s)
- Dongmin Kim
- Cardiology Division, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | | | - Eun Young Kim
- Department of Radiology, Gachon University of Medicine and Science, Incheon, Korea
| | - Jeonggeun Moon
- Division of Cardiology, Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
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Symptomatic Exercise-Induced Left Ventricular Outflow Tract Obstruction without Left Ventricular Hypertrophy. J Am Soc Echocardiogr 2013; 26:556-65. [DOI: 10.1016/j.echo.2013.02.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Indexed: 12/22/2022]
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25
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Beta-blockers for blood pressure augmentation. J Hypertens 2013; 31:422-3. [DOI: 10.1097/hjh.0b013e32835b9811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Semba H, Sawada H, Uejima T, Takeda N, Soma K, Abe H, Yamashita T, Nagai R. Basic echocardiographic features of patients with latent left ventricular outflow tract obstruction without left ventricular hypertrophy. Int Heart J 2012; 53:230-3. [PMID: 22878800 DOI: 10.1536/ihj.53.230] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Left ventricular outflow tract obstruction (LVOTO) is commonly observed in patients with hypertrophic cardiomyopathy (HCM) or left ventricular hypertrophy (LVH). While some patients develop LVOTO at rest, it can also be provoked by physical exertion, and hence termed latent LVOTO (L-LVOTO). Recent reports demonstrated that L-LVOTO develops not only in LVH patients, but also in patients without LVH (non-LVH). However, the prevalence and clinical prognosis of non-LVH patients with L-LVOTO are not yet elucidated. In this study, we retrospectively investigated the echocardiographic features of patients with malignancy who underwent dobutamine stress echocardiography (DSE) to evaluate preoperative cardiac risk. One hundred ninety-nine patients were found not to have LVH or coronary artery disease. Among them, 106 patients exhibited L-LVOTO after DSE. We next compared the baseline echocardiographic features of L-LVOTO (+) patients with those of L-LVOTO (-) patients, and identified the left ventricular outflow tract (LVOT) ratio (systolic LVOT diameter/diastolic LVOT diameter) as a significant predictor of L-LVOTO. An LVOT ratio ≤ 0.83 was the best cutoff value to detect the presence of L-LVOTO, with a sensitivity of 81.1% and specificity of 80.6%. Overall, L-LVOTO was found to develop in almost half of non-LVH patients with malignancy. In addition, the baseline LVOT ratio was strongly related to the presence of L-LVOTO in non-LVH patients. Therefore, patients with dynamic LVOT narrowing may benefit from DSE to detect the presence of L-LVOTO.
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Affiliation(s)
- Hiroaki Semba
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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27
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Stress cardiomyopathy: diagnosis, pathophysiology, management, and prognosis. Crit Pathw Cardiol 2012; 10:142-7. [PMID: 21989035 DOI: 10.1097/hpc.0b013e31822f4d37] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Stress cardiomyopathy is now a well-recognized reversible cardiomyopathy, with a clinical presentation mimicking Acute Coronary syndrome in the absence of significant coronary artery disease. It is often encountered in postmenopausal females and is usually precipitated by acute emotional or physical stressors. In this review, we have attempted to summarize relevant data regarding diagnosis, typical and atypical presentations, pathophysiology, management options, and prognosis. Typically, patients present with chest pain and shortness of breath, transient electrocardiographic changes, moderate troponin elevation, and are found to have wall motion abnormalities (apical and midventricular akinesis with preserved basal segment systolic function) without obstructive coronary lesions, with complete resolution in next few weeks. The precise pathophysiology remains unclear, but excessive catecholamine stimulation, metabolic disturbances, and dysfunction of microcirculation are thought to be the underlying mechanisms.
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29
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Ibrahim M, Rao C, Ashrafian H, Chaudhry U, Darzi A, Athanasiou T. Modern management of systolic anterior motion of the mitral valve. Eur J Cardiothorac Surg 2012; 41:1260-70. [DOI: 10.1093/ejcts/ezr232] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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30
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Isolated dynamic left ventricular outflow tract obstruction can cause hypotension that rapidly responds to intravenous beta blockade. Am J Ther 2012; 18:e172-6. [PMID: 20592665 DOI: 10.1097/mjt.0b013e3181cea0dd] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dynamic left ventricular outflow tract obstruction occurs in hypertrophic cardiomyopathy, stress cardiomyopathy, acute coronary syndromes, and with inotrope use. We describe three critical care patients who developed "isolated" left ventricular outflow tract obstruction with hypotension in the absence of these precipitants. Systolic anterior motion of anterior mitral valve leaflet with peak left ventricular outflow tract gradients of greater than 120 mmHg was noted in Cases 1 and 2. Under close supervision, intravenous (IV) β blocker was initiated with 5 mg metoprolol repeated every 5 minutes up to 15 mg and continued to maintain heart rate less than 70 beats/min. IV fluids were replaced aggressively. Bedside Doppler echocardiogram confirmed near normalization of left ventricular outflow tract gradient with improvement in systolic anterior motion and hypotension within minutes after IV β blocker confirming its specific therapeutic effect. Isolated left ventricular outflow tract obstruction can occur in the absence of recognized precipitants. Early recognition is crucial because this potentially fatal condition responds well to adequate β blocker and IV fluids with rapid relief of hypotension and symptoms.
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31
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Left ventricular outflow tract obstruction and Takotsubo syndrome. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2011.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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32
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy. Circulation 2011; 124:e783-831. [PMID: 22068434 DOI: 10.1161/cir.0b013e318223e2bd] [Citation(s) in RCA: 505] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Bernard J. Gersh
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | - Barry J. Maron
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | | | - Joseph A. Dearani
- Society of Thoracic Surgeons Representative
- American Association for Thoracic Surgery Representative
| | - Michael A. Fifer
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- ACCF/AHA Representative
| | - Mark S. Link
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- Heart Rhythm Society Representative
| | - Srihari S. Naidu
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see for detailed information
- Society for Cardiovascular Angiography and Interventions Representative
| | | | | | - Harry Rakowski
- ACCF/AHA Representative
- American Society of Echocardiography Representative
| | | | | | - James E. Udelson
- Heart Failure Society of America Representative
- American Society of Nuclear Cardiology Representative
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33
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Lousinha A, Gilkeson R, Bezerra H. Left ventricular outflow tract obstruction and Takotsubo syndrome. Rev Port Cardiol 2011; 31:49-51. [PMID: 22154289 DOI: 10.1016/j.repc.2011.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 09/08/2011] [Indexed: 10/14/2022] Open
Affiliation(s)
- Ana Lousinha
- Radiology Department, University Hospitals Case Medical Center, Cleveland, OH, USA
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34
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Different impacts of acute myocardial infarction on left ventricular apical and basal rotation. Eur Heart J Cardiovasc Imaging 2011; 13:483-9. [DOI: 10.1093/ejechocard/jer272] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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35
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, Jacobs AK, Smith SC, Anderson JL, Albert NM, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Nishimura RA, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2011; 142:e153-203. [DOI: 10.1016/j.jtcvs.2011.10.020] [Citation(s) in RCA: 223] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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36
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, Jacobs AK, Smith SC, Anderson JL, Albert NM, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Nishimura RA, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: Executive summary. J Thorac Cardiovasc Surg 2011; 142:1303-38. [DOI: 10.1016/j.jtcvs.2011.10.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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37
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2761-96. [PMID: 22068435 DOI: 10.1161/cir.0b013e318223e230] [Citation(s) in RCA: 594] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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38
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Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 58:2703-38. [PMID: 22075468 DOI: 10.1016/j.jacc.2011.10.825] [Citation(s) in RCA: 196] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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39
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2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e212-60. [PMID: 22075469 DOI: 10.1016/j.jacc.2011.06.011] [Citation(s) in RCA: 824] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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40
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Panduranga P, Maddali MM, Mukhaini MK, Valliattu J. Dynamic left ventricular outflow tract obstruction complicating aortic valve replacement: A hidden malefactor revisited. Saudi J Anaesth 2011; 4:99-101. [PMID: 20927269 PMCID: PMC2945521 DOI: 10.4103/1658-354x.65118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
It is known that a dynamic left ventricular outflow tract (LVOT) obstruction exists in patients, following aortic valve replacement (AVR) and is usually considered to be benign. We present a patient with dynamic LVOT obstruction following AVR, who developed refractory cardiogenic shock and expired inspite of various treatment strategies. This phenomenon must be diagnosed early and should be considered as a serious and potentially fatal complication following AVR. The possible mechanisms and treatment options are reviewed.
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41
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Caselli S, Martino A, Genuini I, Santini D, Carbone I, Agati L, Fedele F. Pathophysiology of dynamic left ventricular outflow tract obstruction in a critically ill patient. Echocardiography 2011; 27:E122-4. [PMID: 20553322 DOI: 10.1111/j.1540-8175.2010.01210.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Left ventricular outflow tract obstruction is not a rare problem in the intensive care units and can precipitate hemodynamic shock unresponsive to catecholamine therapy. The use of echocardiographic examination is extremely important in recognizing this phenomenon and its underlying conditions, finally identifying the most appropriate therapeutic strategy. The simple correction of one or more of these factors can dramatically change patients clinical outcome. We report the clinical case of a 72-year-old man who developed hemodynamic shock in the intensive care unit. Hypovolemia, catecholamine infusion, and mechanical ventilation induced geometric modification of the left ventricle causing a systolic anterior motion of the mitral anterior leaflet and a severe subaortic gradient. Simple restoration of fluids and discontinuation of medical therapy dramatically changed the outcome of the patient. A review of the medical literature has been carried out to deeply investigate pathophysiology of left ventricular outflow tract obstruction in critically ill patients.
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Affiliation(s)
- Stefano Caselli
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy.
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42
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Cardiogenic shock due to dynamic left ventricular outflow tract obstruction in acute myocardial infarction. Clin Res Cardiol 2011; 100:621-5. [DOI: 10.1007/s00392-011-0297-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Accepted: 02/16/2011] [Indexed: 10/18/2022]
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43
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44
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Misumi I, Ebihara K, Akahoshi R, Hirota Y, Sakai A, Sanjo M, Takanaga M, Ueda K. Coronary spasm as a cause of takotsubo cardiomyopathy and intraventricular obstruction. J Cardiol Cases 2010; 2:e83-e87. [PMID: 30524594 DOI: 10.1016/j.jccase.2010.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Revised: 03/27/2010] [Accepted: 03/29/2010] [Indexed: 11/26/2022] Open
Abstract
A 79-year-old man presented to the emergency room because of chest pain on 3 successive mornings. An electrocardiogram (ECG) showed ST segment elevation in leads II, III, and aVF. Laboratory findings including cardiac enzymes, were within normal limits, except a positive result for the troponin T test. Two-dimensional echocardiography revealed akinesis of the left ventricular apex and hyperkinesis of the basal wall. Doppler echocardiography revealed a significant subaortic pressure gradient. Emergent coronary angiography showed no significant coronary artery stenosis, but the ergonovine test induced a right coronary artery spasm with exaggeration of the ST segment elevation in II, III, and aVF leads. The computed tomography performed 2 weeks later showed normal left ventricular wall motion with sigmoid septum. The patient was diagnosed with takotsubo cardiomyopathy and intraventricular obstruction due to coronary spasm; he was treated with calcium channel blockers and nitrates. This case suggests the importance of differential diagnosis of the pathogenesis of takotsubo cardiomyopathy.
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Affiliation(s)
- Ikuo Misumi
- Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi 861-1196, Kumamoto, Japan
| | - Kenji Ebihara
- Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi 861-1196, Kumamoto, Japan
| | - Ryuichiro Akahoshi
- Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi 861-1196, Kumamoto, Japan
| | - Yoshihiko Hirota
- Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi 861-1196, Kumamoto, Japan
| | - Ayako Sakai
- Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi 861-1196, Kumamoto, Japan
| | - Mayumi Sanjo
- Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi 861-1196, Kumamoto, Japan
| | - Megumi Takanaga
- Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi 861-1196, Kumamoto, Japan
| | - Kaori Ueda
- Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi 861-1196, Kumamoto, Japan
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45
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Shoji M, Uejima T, Matsuno S, Oikawa Y, Yajima J, Yamashita T, Koike A, Sawada H, Isobe M, Aizawa T. Dynamic narrowing of left ventricular outflow tract-Possible mechanism of latent left ventricular outflow tract obstruction. J Cardiol Cases 2010; 2:e74-e77. [PMID: 30524593 DOI: 10.1016/j.jccase.2010.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 03/23/2010] [Indexed: 11/25/2022] Open
Abstract
It has been reported that left ventricular outflow tract (LVOT) obstruction can be provoked in patients even without significant left ventricular hypertrophy. We experienced a 74-year-old man with mild degree of left ventricular hypertrophy and latent LVOT obstruction which was successfully treated by alcohol septal ablation. LVOT was not narrow at end-diastole, but proximal septum was protruding further into LVOT during the ejection period, producing a dynamic narrowing of the LVOT. Alcohol septal ablation did not reduce the interventricular septal thickness nor enlarge LVOT. However, it limited the excursion of proximal septum. The effect of the treatment suggested the importance of the dynamic nature of LVOT in the mechanism of latent LVOT obstruction in this case.
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Affiliation(s)
- Masaaki Shoji
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
| | - Tokuhisa Uejima
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
| | - Shunsuke Matsuno
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
| | - Yuji Oikawa
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
| | - Junji Yajima
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
| | - Takeshi Yamashita
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
| | - Akira Koike
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
| | - Hitoshi Sawada
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tadanori Aizawa
- Department of Cardiology, The Cardiovascular Institute, 7-3-10 Roppongi, Minato-ku, Tokyo 106-0032, Japan
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46
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Dhar G, Jolly N. Mechanical versus pharmacologic support for cardiogenic shock. Catheter Cardiovasc Interv 2010; 75:626-9. [PMID: 20049971 DOI: 10.1002/ccd.22229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dynamic left ventricular outflow tract obstruction is a rare cause of cardiogenic shock after an acute myocardial infarction. A case is presented where inotropic support and an intra-aortic balloon pump aggravated the cardiac hemodynamics by this mechanism. The circulatory support provided by Impella 2.5 heart pump, in addition to discontinuation of inotropic support and intra-aortic balloon pump, allowed stabilization and successful percutaneous revascularization.
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Affiliation(s)
- Gaurav Dhar
- Department of Medicine, The University of Chicago Medical Center, Chicago, Illinois 60637, USA
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Vizzardi E, D'Aloia A, Zanini G, Fiorina C, Chiari E, Nodari S, Dei Cas L. Tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome. Int J Clin Pract 2010; 64:67-74. [PMID: 18803556 DOI: 10.1111/j.1742-1241.2008.01833.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
AIMS/OBJECTIVES This review examines the 'tako-tsubo-like' syndrome or transient left ventricular apical ballooning. The aim of this review is a complete evaluation of epidemiology, clinical and instrumental features, pathophysiological mechanisms, therapy and prognosis of this syndrome. METHODS We have evaluated the data from literature for a comprehensive consideration of multiple aspects of this syndrome. RESULTS/FINDINGS Transient left ventricular apical ballooning typically affects women, and the clinical presentation is comparable to acute coronary syndrome with chest pain or sudden dyspnoea, changes in ECG and elevated cardiac enzymes in the absence of significant coronary stenosis, with complete resolution of wall-motion abnormalities in a period of days or weeks. This syndrome is triggered by marked psychological or physiological stress. Several pathophysiological mechanisms have been proposed, such as cathecolamine-mediated cardiotoxicity, abnormalities in coronary microvascular function and multivessel coronary vasospasm. The highest incidence of transient left ventricular apical ballooning is in the Japanese population, but it has been recently identified also in the USA and Europe. Treatment is empirical and supportive. The prognosis is generally favourable, although some deaths have been reported, usually the result of irreversible cardiogenic shock, refractory ventricular arrhythmias, or other catastrophic cardiovascular event. CONCLUSIONS/INTERPRETATIONS We conclude by emphasising the importance of a more deeper knowledge of this syndrome for general physicians and cardiologists and it should be often considered as a possible diagnosis occurring in emergency department and in patients admitted in the Chest Pain Units with a diagnosis of coronary acute syndrome.
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Affiliation(s)
- E Vizzardi
- Section of Cardiovascular Disease, Department of Applied Experimental Medicine, Department of Cardiology, University Study of Brescia, Brescia, Italy.
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FEFER PAUL, CHELVANATHAN ANJALA, DICK ALEXANDERJ, TEITELBAUM EARLJ, STRAUSS BRADLYH, COHEN ERICA. Takotsubo Cardiomyopathy and Left Ventricular Outflow Tract Obstruction. J Interv Cardiol 2009; 22:444-52. [DOI: 10.1111/j.1540-8183.2009.00488.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Affiliation(s)
- Thomas T Tsai
- Denver Veterans Affairs Medical Center and the Department of Internal Medicine, University of Colorado, Denver, CO 80220, USA.
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50
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Pernicova I, Garg S, Bourantas CV, Alamgir F, Hoye A. Takotsubo Cardiomyopathy: A Review of the Literature. Angiology 2009; 61:166-73. [DOI: 10.1177/0003319709335029] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although takotsubo cardiomyopathy is a rare entity, it is an important differential in patients presenting with symptoms, signs, and electrocardiographic changes suggestive of an acute myocardial infarction. Since it was first recognized in 1991, it has gained increasing attention worldwide; however, its etiology and consequently the optimal management still remains unclear. Here, the authors provide a review of the current literature accompanied with images of a typical case from our department.
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Affiliation(s)
- Ida Pernicova
- Department of Cardiology, Hull & East Yorkshire Hospitals NHS Trust, Hull, United Kingdom,
| | - Scot Garg
- Department of Interventional Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | | | - Farqad Alamgir
- Department of Cardiology, Hull & East Yorkshire Hospitals NHS Trust, Hull, United Kingdom
| | - Angela Hoye
- Department of Cardiology, Hull & East Yorkshire Hospitals NHS Trust, Hull, United Kingdom
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